Suturing technique for small wounds
Surgical closure of local defects requires strict adherence to rules so as not to disrupt urodynamics.
- Instruments and materials: A round, sharply curved needle (ideally atraumatic) and absorbable material (catgut in the classical technique) are used.
- Suture placement: Insertion and emergence of the needle are made 1–2 mm away from the wound edge. The distance between interrupted sutures is 2–3 mm.
- Attitude towards layers: It is strictly forbidden to capture the mucous membrane. If the thread enters the lumen, it will become a center for urinary salt crystallization (encrustation).
- Tying: A staged approach is used. First, the surgeon places all necessary sutures along the length of the defect, and only then ties them sequentially, moving from the center of the wound to the lateral edges.
- Stent: To prevent cicatricial narrowing, all manipulations are recommended to be performed over a ureteral catheter inserted into the lumen.
Repair for complete transection
If the organ is completely transected, a standard circular suture will likely lead to a stricture. Therefore, the technique of invagination (telescoping) of one end into the other is used:
- Preparation of the distal end: To increase the diameter of the receiving lumen, the wall of the distal segment is pre-incised in a longitudinal direction.
- Preparation of the proximal end: One or two mattress sutures are applied to it.
- Implantation: The threads from the mattress sutures are passed inside the distal end. The needle is brought out from the inside to the outside. When tension is applied to the threads, the proximal segment is softly pulled into the widened distal one.
Surgery of the pelviureteric junction
Any impairment of patency at the pelviureteric junction inevitably provokes urine stasis and the development of hydronephrosis. The choice of surgery depends on the cause of the obstruction:
- Correction of cicatricial strictures: Based on the Heineke-Mikulicz principle. The narrowed area is incised strictly longitudinally, and the resulting wound is sutured transversely. If maximum expansion is required, both walls in the stricture zone are transected with a scalpel, after which both incisions are sutured.
- Interventions for pelvic dilation: If the renal pelvis is significantly dilated, its resection is performed. This can be an isolated excision of the stretched wall (without affecting the junction itself) or a combined resection of the pelvis and the narrowed ureteral segment. In the second case, a new anastomosis is formed between the remaining part of the pelvis and the transected end of the ureter.
Briefly: answers to topical questions
Which specific layers of the ureteral wall must be captured in the suture to ensure reliable hermetic sealing?
When suturing the ureter, the tissues are captured without involving the mucous membrane. This rule must be followed to avoid encrustation of the sutures with urinary salts. Insertion and emergence of the needle are carried out 1–2 mm away from the wound edges. Interrupted catgut sutures are used, placed at a distance of 2–3 mm from each other. To prevent narrowing, it is recommended to place the sutures over a ureteral catheter inserted into the lumen.
Which eponymous surgeries are used for resection and plasty of the pelviureteric segment in hydronephrosis?
For plasty of the pelviureteric junction in hydronephrosis, surgery based on the Heineke-Mikulicz principle is used.
- The Heineke-Mikulicz principle — the ureteral wall is incised longitudinally at the site of the cicatricial stricture, and then the incision is sutured in the transverse direction.
For better expansion of the junction, both ureteral walls in the stricture area can be transected through with a scalpel and both incisions sutured. With significant dilation of the renal pelvis, its resection is performed with the formation of an anastomosis between the transected ureter and the remaining part of the pelvis.
What reconstructive plasty methods are used for extensive ureteral defects when tension prevents an anastomosis from being created?
For the reconstruction of the ureter in case of its defects, intestinal and bladder plasty methods are used, as well as various types of anastomoses. The reconstruction method is chosen individually:
- Ureterocystostomy — anastomosis of the ureteral stump with the urinary bladder.
- Transureteroureterostomy — connection to the second ureter.
- Boari operation — plasty using a bladder flap.
- Ileoureteroplasty — replacement of the defect with a loop of the small intestine.
A standard end-to-end anastomosis can also be used.
The Rule of Three "NEVER"s in ureteral suturing: NEVER suture the mucosa (risk of stones), NEVER suture without a catheter (risk of stricture), NEVER tie knots immediately (place all threads first).
Class and exam questions
Why should the mucosa not be included when suturing the ureter?
Sutures that end up in the lumen of the urinary tract serve as a matrix for the deposition of urinary salts. This leads to suture encrustation and calculus formation.
How to avoid lumen narrowing during anastomosis?
Oblique cuts of the ureteral ends and Z-suturing techniques are used, and sutures are always placed over a pre-inserted ureteral catheter.
What is the essence of the Heineke-Mikulicz principle in junction strictures?
The cicatricial-narrowed area is incised longitudinally, and the wound edges are sutured transversely. This allows for localized lumen expansion.
How are the ends connected in complete ureteral transection?
The invagination method is used: the proximal end is pulled into the pre-longitudinally incised distal end using mattress sutures.
What else to study on this topic
- Technique of forming a Z-shaped ureteral anastomosis
- Variants of oblique cuts when suturing the ends of the ureter
- Features of pelvic resection in pronounced hydronephrosis
- Biomechanics of the invagination suture in complete transection
- The Heineke-Mikulicz principle in urological practice
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